Autoimmune hepatitis induced by anti-TNF treatment – case report and literature review
Authors:
K. Pavelka 1; S. Franková 2; E. Sticová 3
Authors‘ workplace:
Revmatologický ústav, Praha
1; Klinika hepatogastroenterologie, Institut klinické a experimentální medicíny, Praha
2; Pracoviště klinické a transplantační patologie, Institut klinické a experimentální medicíny, Praha
3
Published in:
Čes. Revmatol., 32, 2024, No. 2, p. 75-81.
Category:
Case Report
Overview
The authors present a case of a 43-year-old female patient with enthesitis form of psoriatic arthritis, HLA-B27 positive. After the failure of conventional treatment, treatment with subcutaneous infliximab (Remsima 120 mg s.c. every 2 weeks) was initiated. The clinical effect was excellent and after several weeks of treatment, her underlying disease went into remission. After 6 months of treatment, the liver function tests rose to AST 4.53 µkat/l and ALT 7.89 µkat/l. At that time she also had positive antinuclear antibodies (ANA) 1:160. Autoimmune hepatitis (AIH) was suspected. On an urgent biopsy, this hypothesis was confirmed. Acute hepatitis with numerous plasmacytes and eosinophils with moderate portal/interface and significant lobular activity and bridging necroses (centro-central, centro-portal), focally with hemorrhage, with signs of liver parenchyma regeneration was found.
In the next part of the publication, the authors give an overview of AIH, which may be one of the autoimmune diseases induced by biological therapy. Simplified criteria for autoimmune hepatitis and an algorithm for investigation in suspected AIH are presented. Furthermore, the treatment strategy is discussed, which is divided into induction and maintenance phases. The first choice drug in the induction phase is glucocorticoids, usually administered at a dose of 0.5 mg/kg/day. The drug of first choice in the maintenance phase is azathioprine. The goal of treatment is to induce biochemical remission within 6 months of initiation of treatment. The long-term prognosis of AIH is uncertain and some patients have to be treated for a long time, sometimes for life. However, the need for liver transplantation is rare.
Keywords:
autoimmune hepatitis – psoriatic arthritis – anti-TNF therapy
Sources
1. Smolen JS, Landewé RBM, Bergstra SA, Kerschbaumer A, Sepriano A, Aletaha D, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023; 82(1): 3–18.
2. Gossec L, Baraliakos X, Kerschbaumer A, de Wit M, McInnes I, Dougados M, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 Update. Ann Rheum Dis. 2020; 79: 700–712.
3. Perez-Alvarez R, Pérez-de-Lis M, Ramos-Casals M; BIOGEAS study group. Biologics – induced autoimmune diseases. Cur Opin Rheumatol. 2013; 25: 56–64.
4. de Bandt M, Sibilia J, Le Loët X, Prouzeau S, Fautrel B, Marcelli C, et al; Club Rhumatismes et Inflammation. Systemic lupus erythematosus induced by anti-tumour necrosis factor alpha therapy: a French national survey. Arthritis Res Ther. 2005; 7(3): R545–551.
5. Ramos-Casals M, Roberto-Perez-Alvarez, Diaz-Lagares C, Cuadrado MJ, Khamashta MA; BIOGEAS Study Group. Autoimmune diseases induced by biological agents: a double-edged sword? Autoimmun Rev. 2010; 9(3): 188–193.
6. Muratori L, Lohse AW, Lenzi M. Diagnosis and management of autoimmune hepatitis. BMJ 2023; 380: e070201.
7. Hennes EM, Zeniya M, Czaja AJ, Parés A, Dalekos GN, Krawitt EL, et al. International Autoimmune Hepatitis Group. Simplified criteria for the diagnosis of autoimmune hepatitis. Hepatology 2008; 48(1): 169–176.
8. Grønbæk L, Vilstrup H, Jepsen P. Autoimmune hepatitis in Denmark: incidence, prevalence, prognosis, and causes of death. A nationwide registry-based cohort study. J Hepatol. 2014; 60(3): 612–617.
9. Ricciuto A, Kamath BM, Walters TD, Frost K, Carman N, Church PC, et al. New onset autoimmune hepatitis during anti-Tumor necrosis factor-alpha treatment in children. J Pediatr. 2018; 194: 128–135.
10. Rahim MN, Miquel R, Heneghan MA. Approach to the patient with acute severe autoimmune hepatitis. JHEP Rep. 2020; 2(6): 100149.
11. Galaski J, Weiler-Normann C, Schakat M, Zachou K, Muratori P, Lampalzer S, et al. Update of the simplified criteria for autoimmune hepatitis: Evaluation of the methodology for immunoserological testing. J Hepatol. 2021; 74(2): 312–320.
12. Ghabril M, Bonkovsky HL, Kum C, Davern T, Hayashi PH, Kleiner DE, et al.; US Drug-Induced Liver Injury Network. Liver injury from tumor necrosis factor-α antagonists: analysis of thirty-four cases. Clin Gastroenterol Hepatol. 2013; 11(5): 558–564.
13. Vollmer O, Felten R, Mertz P, Lebrun-Vignes B, Salem JE, Arnaud L. Characterization of auto-immune hepatitis associated with the use of anti-TNF-α agents: An analysis of 389 cases in VigiBase. Autoimmun Rev. 2020; 19(3): 102460.
14. Pape S, Gevers TJG, Belias M, Mustafajev IF, Vrolijk JM, van Hoek B, et al. Predniso(lo)ne dosage and chance of remission in patients with autoimmune hepatitis. Clin Gastroenterol Hepatol. 2019; 17(10): 2068–2075.
15. Webb GJ, Rana A, Hodson J, Akhtar MZ, Ferguson JW, Neuberger JM, et al. Twenty-year comparative analysis of patients with autoimmune liver diseases on transplant waitlists. Clin Gastroenterol Hepatol. 2018; 16(2): 278–287.
16. Umekita K, Miyauchi S, Ueno S, Takajo I, Kusumoto K, Hasuike S, et al. Improvement of rheumatoid arthritis and autoimmune hepatitis in a patient treated with the tumor necrosis factor inhibitor, etanercept. Intern Med. 2011; 50(11): 1245–1249.
Labels
Dermatology & STDs Paediatric rheumatology RheumatologyArticle was published in
Czech Rheumatology
2024 Issue 2
Most read in this issue
- Autoimmune hepatitis induced by anti-TNF treatment – case report and literature review
- Mechanisms of chronic pain and clinical aspects of pain in patients with rheumatoid arthritis
- Eosinophilic granulomatosis with polyangiitis in inovative rheumatology
- EULAR recommendations for the non-pharmacological management of systemic lupus erythematosus and systemic sclerosis